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General NPI Number Information
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NPI Number | 1164912754
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Entity Type | Organization
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Legal Business Name | SUPERIOR PHYSICIAN GROUP
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Dates
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Enumeration Date | 05/18/2018
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 10730 N 56TH ST STE 209
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617
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Country | US
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Telephone | 813-365-5680
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Fax |
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Provider Business Mailing Address
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Address Line | 10730 N 56TH ST STE 209
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617-3611
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Country | US
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Telephone | 813-365-5680
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | MS. RENII MODISETTE
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Credential |
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Telephone | 813-365-5680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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